Professional Issues
Guadalupe R. Palos, RN, LMSW, DrPH—Associate Editor
Stress Among New Oncology Nurses Rowida Mohammed Naholi, MSN, RN, Cheryl L. Nosek, DNS, RN, CNE, and Darryl Somayaji, PhD, RN, CNS, CCRC
New oncology nurses face multiple stressors related to the predicted nursing shortage, demanding work responsibilities, and growing complexity of cancer care. The confluence of these stressors often causes new nurses to leave their profession. The loss of new nurses leads to staffing, economic, and safety concerns, which have a significant impact on the quality of oncology nursing care. At a Glance • Oncology nurses are valuable resources in the healthcare system. • A promising source of support identified by new oncology nurses is the use of a nurse educator coach to guide them on how to integrate self-care strategies into daily practice. • The findings from the current study can be used to develop innovative interventions to achieve optimal job satisfaction, retention rates, and professional experience for new oncology nurses. Rowida Mohammed Naholi, MSN, RN, is an oncology clinical instructor at the King Fahed Specialist Hospital in Dammam, Saudi Arabia; Cheryl L. Nosek, DNS, RN, CNE, is an associate professor in the Division of Health and Human Services at Daemen College in Amherst, NY; and Darryl Somayaji, PhD, RN, CNS, CCRC, is a postdoctoral research fellow in cancer and health disparities at the Dana-Farber/Harvard Cancer Center in Boston, MA. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the authors or editorial staff. Naholi can be reached at rowida.naholi@daemen .edu, with copy to editor at [email protected]. Key words: stress; coping; coping strategies Digital Object Identifier: 10.1188/15.CJON.115-117
O
ncology nursing has been described as one of the most stressful specialty areas (Lederberg, 1989). Several studies have demonstrated that providing care for patients with cancer is a stressful occupation for nurses (Campos de Carvalho, Muller, Bachion de Carvalho, & de Souza Melo, 2005; Isikhan, Comez, & Danis, 2004). Workrelated stress has a significant impact on the oncology nursing workforce. The oncology field is a complex environment in which to work because it requires nurses who are educated, skilled, and clinically competent to care for patients with cancer. Nurses also support their families through the treatment process and, perhaps, dying and death as
well (Kravits, McAllister-Black, Grant, & Kirk, 2010). The factors, levels, response to, and consequences of stress on the professional and personal well-being of the oncology nurse has been the focus of a growing body of research. Factors causing stress in oncology nurses are associated with the growing shortage of nurses, characteristics of the work environment, and conflicting feelings of working with patients (Engel, 2004; McVicar, 2003). The purpose of this article is to examine the experience, sources of stress, and preferences for selfmanagement or educational programs reported by new oncology nurses when transitioning into the oncology work environment.
Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Professional Issues
Methods This study used the survey research method. The protocol was approved by the Human Subjects Review committee at Daemen College in Amherst, NY. Data were collected during the spring of 2013. Participants were recruited from a large cancer center in New York state, which gave approval prior to the recruitment of participants, and used a convenience sample of 42 oncology nurses who were aged 18 years or older, able to read and write English, assigned to direct patient care, willing to complete the survey, and had less than three years’ experience in the oncology field. The participants used SurveyMonkey ® to respond and were assured of confidentiality. A questionnaire packet and a standardized interview guide were used for this study. The packet consisted of a five-part questionnaire that contained (a) demographic questions, (b) the Nurse Stress Scale (NSS) (Gray-Toft & Anderson, 1981), (c) an instrument measuring coping strategies used by nurses (US1), (d) questions asking about the types of coping strategies that nurse educators could use to help teach nurses how to cope with stress, and (e) open-ended questions that were used to understand new oncology nurses’ perception of stress and suggest possible coping strategies for stressful situations.
Findings The first part was the respondents’ background characteristics, which showed that 42 nurses completed the survey, 39 were female, and 32 ranged in age from 21–36 years. Regarding work experience, 20 of the nurses reported working one year or less. Twenty-three 115
Mean Scores
nurses reported that they were 2.5 not thinking about leaving their job, whereas 19 nurses were 2.0 thinking about leaving their job. The second part of the study identified the frequency with 1.5 which new oncology nurses working in a hospital experi1.0 enced stress in the performance of their duties, as measured using the NSS (Gray-Toft & Ander0.5 son, 1981). Figure 1 summarizes the mean scores for the most 0 frequent stress factors reported by the nurses. The factors were Workload Death and Conflict Inadequate Conflict Uncertainty Lack of dying with other preparation with concerning support workload, death and dying, inadnurses physicians treatment equate preparation, conflict with Sources of Stress physicians, uncertainty concernNote. Higher scores indicate more frequent stress. ing treatment, conflict with other nurses, and lack of support. FIGURE 1. Sources of Stress in New Oncology Nurses (N = 42) No significant association was noted between age and level of stress as reflected by the NSS. coping strategies, whereas “having an found that the most stressful factors for However, nurses with higher stress opportunity to participate in continuing new oncology nurses were the unpredictlevels were more likely to think about education” and “keeping the same clinical able workload, dealing with death and leaving their current work. Nurses who instructor during the entire orientation dying, and inadequate preparation for answered “yes” regarding intent to — period” were the least favored for coping their job. Similar findings were reported leave registered higher stress ( X = 2.14, with stress. in a robust literature review suggesting SD = 0.28) than those who answered “no” — Responses indicated that the most nurses who reported various frustrations ( X = 1.89, SD = 0.314). This difference stressful aspect of nurses’ work clustered did not experience a nurturing work was statistically significant (p = 0.013). around three categories: the nature of the environment (McVicar, 2003). Some reThe four most frequently used coppatients, insufficient education and trainsearchers have reported that a supportive ing behaviors identified were sleeping, ing programs, and conflict in the work work environment for new oncology drinking coffee, developing a personal environment. Other coping behaviors nurses significantly contributed to better perspective about the value of the work, nurses used to deal with their stress injob satisfaction and less stress (Greco, Lasand participating in entertaining accluded praying, listening to music, taking chinger, & Wong, 2006; McVicar, 2003). tivities and eating. No significant assomedication, and talking with other new Current findings suggest effective interciations were noted among age, work nurses or friends. Nurses also reported ventions are needed to support nursing experience, nurses’ thoughts about leavneeding a supportive work environment practice, job satisfaction, and patient ing their current job, and use of coping as well as more support from their susafety in the delivery of cancer nursing behaviors among new oncology nurses. pervisor. One interesting intervention care by novice nurses. Independent samples, t-tests, and onesuggested was the use of a nurse educator These findings have implications for way analysis of variance tests were used coach to provide support, guidance, and nurse educators, managers, and executo assess the differences of stress, copeducation during the transition period. tive leadership in developing education ing behaviors, and coping strategies by programs and stress management interage, gender, and years of experience. ventions for new oncology nurses. For No significant associations were noted example, educational programs can eduamong age (p = 0.055), work experience cate new nurses on ways to adapt to their (p = 0.191), nurses’ intent to leave their Work-related stress has a significant imnew roles, communicate their needs, and current job (p = 0.109), and use of coping pact on the oncology nursing workforce. establish realistic professional growth behaviors among new oncology nurses. Stress experienced by the new oncology goals. Educational programs could also Another area of interest was to identify nurse affects their job satisfaction, desire teach self-management techniques to coping strategies that nurse educators to stay in nursing and, most important, reduce high stress levels. Younger nurses can use to help new oncology nurses physical and psychological health. The (aged 35 years or younger) reported ushandle the stress. Among the eight coping authors’ findings are consistent with ing coping behaviors more often than strategies, “hearing motivational words,” other empirical research (Alacacioglu, older respondents. Younger nurses also “hearing words of appreciation,” and Yavuzsen, Dirioz, Oztop, & Yilmaz, 2009; preferred to have those strategies taught “getting emotional support from my manRodrigues & Chaves, 2008). The authors by the nurse educators. Preferences such ager” were reported as the most preferred
Discussion and Implications
116
February 2015 • Volume 19, Number 1 • Clinical Journal of Oncology Nursing
as these can be integrated into programs focusing on generational differences and their impact on the work environment. In addition, new oncology nurses indicated the need for stronger support and more resources from managers and organizational leadership. This information can be used to create tailored didactic and clinical programs specific to new oncology nurses.
Conclusion As new nurses enter the workforce, identifying methods that will prepare them for the delivery of safe and highquality oncology care is critical. Because oncology nursing is stressful, methods should be identified that will reduce the high level of stress. The current article identifies factors causing stress in new oncology nurses and coping behaviors preferred by this group of nurses. The findings regarding the coping behaviors and strategies can be used in future orientation or continuing education programs to initiate discussions with novice nurses about work-related stress and strategies that can manage stress. The Future of Nursing: Leading Change, Advancing Health report also recommended the use of nurse residency programs to help nurses adapt to their new roles and reduce first-year turnover rate (Institute of Medicine, 2010). The current nursing shortage and high turnover rates threaten the safety and quality of patient care (American Association of Colleges of Nursing, 2014); therefore, healthcare organizations must recognize the critical
need to provide a supportive environment and additional training for new nurses to achieve a long and successful oncology nursing career.
References Alacacioglu, A., Yavuzsen, T., Dirioz, M., Oztop, I., & Yilmaz, U. (2009). Burnout in nurses and physicians working at an oncology department. Psycho-Oncology, 18, 543–548. doi:10.1002/pon.1432 American Association of Colleges of Nursing. (2014). Nursing shortage. Retrieved from http://aacn.nche.edu/media-relations/ fact-sheets/nursing-shortage Campos de Carvalho, E., Muller, M., Bachion de Carvalho, P., & de Souza Melo, A. (2005). Stress in the professional practice of oncology nurses. Cancer Nursing, 28, 187–192. Engel, B. (2004). Are we out of our minds with nursing stress? Creative Nursing, 10, 4–6. Gray-Toft, P., & Anderson, J.G. (1981). Stress among hospital nursing staff: Its causes and effects. Social Science Medicine, 15A, 639–647. Greco, P., Laschinger, H.K., & Wong, C., (20 06). Leader empower i ng behaviors, staff nurse empowerment, and work engagement/burnout. Nursing
Leadership, 19, 41–56. doi:10.12927/ cjnl.2006.18599 Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Isikhan, V., Comez, T., & Danis, M. (2004). Job stress and coping strategies in health care professionals working with cancer patients. European Journal of Oncology Nursing, 8, 234–244. Kravits, K., McAllister-Black, R., Grant, M., & Kirk, C. (2010). Self-care strategies for nurses: A psycho-educational intervention for stress reduction and the prevention of burnout. Applied Nursing Research, 23, 130–138. doi:10.1016/j .apnr.2008.08.002 Lederberg, M. (1989). Psychological problems of staff and their management. In J.C. Holland & J. Rowland (Eds.), Handbook of psycho-oncology (pp. 631–646). New York, NY: Oxford University Press. McVicar, A. (2003). Workplace stress in nursing: A literature review. Journal of Advanced Nursing, 44, 633–642. doi:10.1046/j.0309-2402.2003.02853.x Rodrigues, A., & Chaves, E. (2008). Stressing factors and coping strategies used by oncology nurses. Revista LatinoAmericana de Enfermagem, 16, 24–28. doi:10.1590/S0104-11692008000100004
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Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Professional Issues
117
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Guadalupe R. Palos, RN, LMSW, DrPH—Associate Editor
Stress Among New Oncology Nurses Rowida Mohammed Naholi, MSN, RN, Cheryl L. Nosek, DNS, RN, CNE, and Darryl Somayaji, PhD, RN, CNS, CCRC
New oncology nurses face multiple stressors related to the predicted nursing shortage, demanding work responsibilities, and growing complexity of cancer care. The confluence of these stressors often causes new nurses to leave their profession. The loss of new nurses leads to staffing, economic, and safety concerns, which have a significant impact on the quality of oncology nursing care. At a Glance • Oncology nurses are valuable resources in the healthcare system. • A promising source of support identified by new oncology nurses is the use of a nurse educator coach to guide them on how to integrate self-care strategies into daily practice. • The findings from the current study can be used to develop innovative interventions to achieve optimal job satisfaction, retention rates, and professional experience for new oncology nurses. Rowida Mohammed Naholi, MSN, RN, is an oncology clinical instructor at the King Fahed Specialist Hospital in Dammam, Saudi Arabia; Cheryl L. Nosek, DNS, RN, CNE, is an associate professor in the Division of Health and Human Services at Daemen College in Amherst, NY; and Darryl Somayaji, PhD, RN, CNS, CCRC, is a postdoctoral research fellow in cancer and health disparities at the Dana-Farber/Harvard Cancer Center in Boston, MA. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the authors or editorial staff. Naholi can be reached at rowida.naholi@daemen .edu, with copy to editor at [email protected]. Key words: stress; coping; coping strategies Digital Object Identifier: 10.1188/15.CJON.115-117
O
ncology nursing has been described as one of the most stressful specialty areas (Lederberg, 1989). Several studies have demonstrated that providing care for patients with cancer is a stressful occupation for nurses (Campos de Carvalho, Muller, Bachion de Carvalho, & de Souza Melo, 2005; Isikhan, Comez, & Danis, 2004). Workrelated stress has a significant impact on the oncology nursing workforce. The oncology field is a complex environment in which to work because it requires nurses who are educated, skilled, and clinically competent to care for patients with cancer. Nurses also support their families through the treatment process and, perhaps, dying and death as
well (Kravits, McAllister-Black, Grant, & Kirk, 2010). The factors, levels, response to, and consequences of stress on the professional and personal well-being of the oncology nurse has been the focus of a growing body of research. Factors causing stress in oncology nurses are associated with the growing shortage of nurses, characteristics of the work environment, and conflicting feelings of working with patients (Engel, 2004; McVicar, 2003). The purpose of this article is to examine the experience, sources of stress, and preferences for selfmanagement or educational programs reported by new oncology nurses when transitioning into the oncology work environment.
Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Professional Issues
Methods This study used the survey research method. The protocol was approved by the Human Subjects Review committee at Daemen College in Amherst, NY. Data were collected during the spring of 2013. Participants were recruited from a large cancer center in New York state, which gave approval prior to the recruitment of participants, and used a convenience sample of 42 oncology nurses who were aged 18 years or older, able to read and write English, assigned to direct patient care, willing to complete the survey, and had less than three years’ experience in the oncology field. The participants used SurveyMonkey ® to respond and were assured of confidentiality. A questionnaire packet and a standardized interview guide were used for this study. The packet consisted of a five-part questionnaire that contained (a) demographic questions, (b) the Nurse Stress Scale (NSS) (Gray-Toft & Anderson, 1981), (c) an instrument measuring coping strategies used by nurses (US1), (d) questions asking about the types of coping strategies that nurse educators could use to help teach nurses how to cope with stress, and (e) open-ended questions that were used to understand new oncology nurses’ perception of stress and suggest possible coping strategies for stressful situations.
Findings The first part was the respondents’ background characteristics, which showed that 42 nurses completed the survey, 39 were female, and 32 ranged in age from 21–36 years. Regarding work experience, 20 of the nurses reported working one year or less. Twenty-three 115
Mean Scores
nurses reported that they were 2.5 not thinking about leaving their job, whereas 19 nurses were 2.0 thinking about leaving their job. The second part of the study identified the frequency with 1.5 which new oncology nurses working in a hospital experi1.0 enced stress in the performance of their duties, as measured using the NSS (Gray-Toft & Ander0.5 son, 1981). Figure 1 summarizes the mean scores for the most 0 frequent stress factors reported by the nurses. The factors were Workload Death and Conflict Inadequate Conflict Uncertainty Lack of dying with other preparation with concerning support workload, death and dying, inadnurses physicians treatment equate preparation, conflict with Sources of Stress physicians, uncertainty concernNote. Higher scores indicate more frequent stress. ing treatment, conflict with other nurses, and lack of support. FIGURE 1. Sources of Stress in New Oncology Nurses (N = 42) No significant association was noted between age and level of stress as reflected by the NSS. coping strategies, whereas “having an found that the most stressful factors for However, nurses with higher stress opportunity to participate in continuing new oncology nurses were the unpredictlevels were more likely to think about education” and “keeping the same clinical able workload, dealing with death and leaving their current work. Nurses who instructor during the entire orientation dying, and inadequate preparation for answered “yes” regarding intent to — period” were the least favored for coping their job. Similar findings were reported leave registered higher stress ( X = 2.14, with stress. in a robust literature review suggesting SD = 0.28) than those who answered “no” — Responses indicated that the most nurses who reported various frustrations ( X = 1.89, SD = 0.314). This difference stressful aspect of nurses’ work clustered did not experience a nurturing work was statistically significant (p = 0.013). around three categories: the nature of the environment (McVicar, 2003). Some reThe four most frequently used coppatients, insufficient education and trainsearchers have reported that a supportive ing behaviors identified were sleeping, ing programs, and conflict in the work work environment for new oncology drinking coffee, developing a personal environment. Other coping behaviors nurses significantly contributed to better perspective about the value of the work, nurses used to deal with their stress injob satisfaction and less stress (Greco, Lasand participating in entertaining accluded praying, listening to music, taking chinger, & Wong, 2006; McVicar, 2003). tivities and eating. No significant assomedication, and talking with other new Current findings suggest effective interciations were noted among age, work nurses or friends. Nurses also reported ventions are needed to support nursing experience, nurses’ thoughts about leavneeding a supportive work environment practice, job satisfaction, and patient ing their current job, and use of coping as well as more support from their susafety in the delivery of cancer nursing behaviors among new oncology nurses. pervisor. One interesting intervention care by novice nurses. Independent samples, t-tests, and onesuggested was the use of a nurse educator These findings have implications for way analysis of variance tests were used coach to provide support, guidance, and nurse educators, managers, and executo assess the differences of stress, copeducation during the transition period. tive leadership in developing education ing behaviors, and coping strategies by programs and stress management interage, gender, and years of experience. ventions for new oncology nurses. For No significant associations were noted example, educational programs can eduamong age (p = 0.055), work experience cate new nurses on ways to adapt to their (p = 0.191), nurses’ intent to leave their Work-related stress has a significant imnew roles, communicate their needs, and current job (p = 0.109), and use of coping pact on the oncology nursing workforce. establish realistic professional growth behaviors among new oncology nurses. Stress experienced by the new oncology goals. Educational programs could also Another area of interest was to identify nurse affects their job satisfaction, desire teach self-management techniques to coping strategies that nurse educators to stay in nursing and, most important, reduce high stress levels. Younger nurses can use to help new oncology nurses physical and psychological health. The (aged 35 years or younger) reported ushandle the stress. Among the eight coping authors’ findings are consistent with ing coping behaviors more often than strategies, “hearing motivational words,” other empirical research (Alacacioglu, older respondents. Younger nurses also “hearing words of appreciation,” and Yavuzsen, Dirioz, Oztop, & Yilmaz, 2009; preferred to have those strategies taught “getting emotional support from my manRodrigues & Chaves, 2008). The authors by the nurse educators. Preferences such ager” were reported as the most preferred
Discussion and Implications
116
February 2015 • Volume 19, Number 1 • Clinical Journal of Oncology Nursing
as these can be integrated into programs focusing on generational differences and their impact on the work environment. In addition, new oncology nurses indicated the need for stronger support and more resources from managers and organizational leadership. This information can be used to create tailored didactic and clinical programs specific to new oncology nurses.
Conclusion As new nurses enter the workforce, identifying methods that will prepare them for the delivery of safe and highquality oncology care is critical. Because oncology nursing is stressful, methods should be identified that will reduce the high level of stress. The current article identifies factors causing stress in new oncology nurses and coping behaviors preferred by this group of nurses. The findings regarding the coping behaviors and strategies can be used in future orientation or continuing education programs to initiate discussions with novice nurses about work-related stress and strategies that can manage stress. The Future of Nursing: Leading Change, Advancing Health report also recommended the use of nurse residency programs to help nurses adapt to their new roles and reduce first-year turnover rate (Institute of Medicine, 2010). The current nursing shortage and high turnover rates threaten the safety and quality of patient care (American Association of Colleges of Nursing, 2014); therefore, healthcare organizations must recognize the critical
need to provide a supportive environment and additional training for new nurses to achieve a long and successful oncology nursing career.
References Alacacioglu, A., Yavuzsen, T., Dirioz, M., Oztop, I., & Yilmaz, U. (2009). Burnout in nurses and physicians working at an oncology department. Psycho-Oncology, 18, 543–548. doi:10.1002/pon.1432 American Association of Colleges of Nursing. (2014). Nursing shortage. Retrieved from http://aacn.nche.edu/media-relations/ fact-sheets/nursing-shortage Campos de Carvalho, E., Muller, M., Bachion de Carvalho, P., & de Souza Melo, A. (2005). Stress in the professional practice of oncology nurses. Cancer Nursing, 28, 187–192. Engel, B. (2004). Are we out of our minds with nursing stress? Creative Nursing, 10, 4–6. Gray-Toft, P., & Anderson, J.G. (1981). Stress among hospital nursing staff: Its causes and effects. Social Science Medicine, 15A, 639–647. Greco, P., Laschinger, H.K., & Wong, C., (20 06). Leader empower i ng behaviors, staff nurse empowerment, and work engagement/burnout. Nursing
Leadership, 19, 41–56. doi:10.12927/ cjnl.2006.18599 Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Isikhan, V., Comez, T., & Danis, M. (2004). Job stress and coping strategies in health care professionals working with cancer patients. European Journal of Oncology Nursing, 8, 234–244. Kravits, K., McAllister-Black, R., Grant, M., & Kirk, C. (2010). Self-care strategies for nurses: A psycho-educational intervention for stress reduction and the prevention of burnout. Applied Nursing Research, 23, 130–138. doi:10.1016/j .apnr.2008.08.002 Lederberg, M. (1989). Psychological problems of staff and their management. In J.C. Holland & J. Rowland (Eds.), Handbook of psycho-oncology (pp. 631–646). New York, NY: Oxford University Press. McVicar, A. (2003). Workplace stress in nursing: A literature review. Journal of Advanced Nursing, 44, 633–642. doi:10.1046/j.0309-2402.2003.02853.x Rodrigues, A., & Chaves, E. (2008). Stressing factors and coping strategies used by oncology nurses. Revista LatinoAmericana de Enfermagem, 16, 24–28. doi:10.1590/S0104-11692008000100004
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Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Professional Issues
117
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
